Form Ccp 4 Health And Safety Self-Certification (For License-Exempt Providers)
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND SAFETY SELF-CERTIFICATION
COUNTY USE ONLY
(For license-exempt providers)
CASE NAME
INSTRUCTIONS:
As a license-exempt child care provider (family, friend or
CLIENT CASE NUMBER
neighbor) who is serving a family that receives subsidized child care services, you
must fill out this form. Please complete the form, and return it promptly to the County
WORKER NAME
Welfare Department, Alternative Payment Program or other payment agency.
WORKER NUMBER
PART A PROVIDER INFORMATION:
1. Name of Provider _____________________________________Provider’s Date of Birth ______/_______/_______
Address___________________________________________City_____________________State_____Zip
__________
Phone (
)
______________________________
The State of California requires proof that you are at least 18 years of age or older. Please attach a copy of your driver’s
license or other proof of age.
2. Family Receiving Care.
Name of Parent/Responsible Adult_________________________________________Phone (
)
________________
Address_______________________________________________City________________State______Zip
__________
I
I
3. Child care will be provided in (check one):
Child’s Home
Provider’s Home
PART B HEALTH AND SAFETY SELF-CERTIFICATION REQUIREMENTS:
The home where you provide care must meet safety requirements. The health and safety standards are listed below. It is
the ongoing responsibility of the parent and the provider to see that these basic standards are met.
If the statement is correct, the parent/responsible adult and provider must put their initials to the left of it. This will certify that
the home meets health and safety standards.
Parent/
Responsible
Provider’s
Adult
Initials
Initials
1.
________
________
The home where child care is provided has working smoke detectors and fire extinguishers
that meet standards set by the State Fire Marshal.
2.
________
________
The child care provider will not use corporal, harsh, or unusual punishment.
3.
________
________
The child care provider must allow unlimited parental access to the children while in their
care.
4.
________
________
The child care provider must not have a communicable disease and, must be physically
and mentally capable of caring for children. The provider must show proof to the parent that
he/she was tested in the last 12 months and is free of active tuberculosis.
5.
________
________
The home where child care is provided has yard and play areas that have been checked
and are safe for children. Children are protected from dangers such as pools, hot tubs,
electrical outlets, stairs, poisonous materials, medications, guns and/or ammunition etc.
6.
________
________
There are at least two local character references that will attest to the good character of the
child care provider and his/her ability to provide child care in a safe environment. See part
C on the next page.
Information about health and safety and other basic child care training is available from the local Child Care Resource and
Referral Program and other community agencies such as the American Red Cross, Community Colleges, Fire Departments,
etc.
The parent and provider are encouraged to use the Health & Safety Facility Checklist (CCP 6) to ensure that the home
where care is to be provided is safe for children.
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CCP 4 (10/14) REQUIRED FORM -SUBSTITUTES PERMITTED
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